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North Carolina Inclusion Works Provider Innovation Program Application

Agency and Contacts

The information shared in this application will aid in selection of the 8 agencies participating in the Provider Innovation Program.
1.Agency Name:(Required.)
2.Agency Address:(Required.)
3.Agency Phone Number:(Required.)
4.Agency Website Link:(Required.)
5.Agency Social Media Account Link(s):
6.Agency Executive Director/CEO name:(Required.)
7.Agency Executive Director/CEO Email:(Required.)
8.Agency Executive Director/CEO phone number:(Required.)
9.Project Agency Designated Lead name:(Required.)
10.Project Agency Designated Lead email:(Required.)
11.Project Designated Lead phone number:(Required.)
12.Names/Emails/Phone Numbers for other Agency Key Provider Project team members:(Required.)
13.Please describe your organization:(Required.)
14.Your agency's total number of employees:(Required.)
15.Your agency's total number of employees providing employment services:(Required.)
16.Total number of people with Intellectual and Developmental Disabilities that you support:(Required.)
17.Number of people earning less than $7.25 per hour:(Required.)
18.List the types of services you provide and number of people you support in each:(Required.)
19.What LME/MCOs are you affiliated with?
20.Locations where you provide services:(Required.)
21.Please list all of the funding sources your organization utilizes to provide services and the percentage of your funding that they represent. (Employment Services %, Other Services Funding %, fundraising/philanthropy %, other %):(Required.)
22.What is your organization’s mission?(Required.)
23.What are your organization’s values?(Required.)
COMPETITIVE INTEGRATED EMPLOYMENT DEFINITION:
Competitive integrated employment (CIE) is defined by the Workforce Innovation and Opportunity Act (WIOA) as work that is performed on a full-time or part-time basis for which an individual is:
Compensated at or above minimum wage and comparable to the customary rate paid by the employer to employees without disabilities performing similar duties and with similar training and experience;
Receiving the same level of benefits provided to other employees without disabilities in similar positions;
At a location where the employee interacts with other individuals without disabilities; and
Presented opportunities for advancement similar to other employees without disabilities in similar positions.
24.Describe your organization’s experience with competitive integrated employment:(Required.)
25.Total number of employees providing Competitive Integrated Employment (CIE) supports? Please list group and individual CIE separately.(Required.)
26.Number of individuals working in Competitive Integrated Employment Jobs:(Required.)
27.Number of individuals working in non-Competitive Integrated Employment jobs:(Required.)